MEDICARE: KIMBERLY ANN VONDERLIETH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9101648	FL
2	363AS0400X	Surgical Physician Assistant	PA9101648	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LS853	OTHER	FL	FL MEDICARE
3	LY388	OTHER	FL	FL MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396917522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ANN VONDERLIETH PA

Provider Business Mailing Address
First Line	:	3300 S FISKE BLVD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-4306
Country	:	US
Telephone Number	:	321-434-3420
Fax Number	:

Provider Business Practice Location Address
First Line	:	1251 HICKORY ST
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-3221
Country	:	US
Telephone Number	:	321-434-3420
Fax Number	:	321-434-3423

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2008
Last Update Date	:	11/17/2025

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Directions to “ KIMBERLY ANN VONDERLIETH PA” Practice Location

Language	Start Address	Practice Location

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